Differential Diagnosis of Local
Cervical Syndrome versus Cervical
Brachial Syndrome
Phillip S. Sizer, Jr., MEd, PT; Valerie Phelps, PT; Jean Michel Brismee, MS, PT
School of Allied Health, Texas Tech University Health Sciences Center, Lubbock, Texas
C ervical pain is a common affliction experienced by
most individuals at one time or another in life.
This commonality inspired Bland to suggest that Pain
in the neck is such an everyday event that it is often used
to describe a situation, certain people, an unpleasant job
to be done, or an institution.1 This commonality pre-
sents a great challenge for clinicians, whose task of diag-
nosis and treatment is complicated by the structural and
functional complexities found in the cervical region.
Not only does the cervical spine function as a very sensi-
tive sensory organ, but it also demonstrates prevalent
three-dimensional coupling behaviors. These physiolog-
ical and mechanical intricacies lend to clinical conse-
quences that could easily mislead the clinician in diagno-
sis and treatment of cervical disorders.
Authors have attempted to classify cervical disorders
from structural and functional perspectives. Winkel et al
clinically categorized cervical disorders in the following
fashion, based on the location of the symptoms related to
the disorder: (1) Local Cervical Syndrome (LCS); (2) Cer-
vico-Brachial Syndrome (CBS); (3) Cervico-Cephalic Syn-
drome; and (4) Cervico-Medullary Syndrome.2 Within
each of these categories, various etiologies were observed
that might explain the pattern and behavior of the related
symptoms.
Address correspondence and reprint requests to: Phillip S. Sizer Jr, MEd,
PT, Texas Tech University Health Science Center, School of Allied Health,
Physical Therapy Program, 3601 4th Street, Lubbock, Texas 79430. U.S.A.
2001 Blackwell Science Inc., 1530-7085/01/$15.00
Pain Practice, Volume 1, Number 1, 2001 2135
One can describe LCS as a disorder that presents with
local neck complaints, due to either 1 or 2 disc-related
conditions. In a 1 disc-related LCS, the patient suffers
due to pain generation from the disc itself, as the disc is
a structure with the capacity for generating both priop-
rioceptive and nociceptive afferent information. While
the cervical disc segments can produce observable radio-
graphic changes associated with disc protrusion, a LCS
can also emerge from an internal disc disruption with-
out any findings on standard MRI or CT, making the di-
agnosis more challenging for the clinician.
LCS can also be related to 2 disc-related changes.
Local cervical symptoms can stem from long-standing
changes in the articular structures of the cervical spine
that were triggered by previous degradation in the inter-
vertebral disc. Similar to the lumbar spine, pain can
emerge from the zygapophyseal joints (ZAJ), as these
joints experience significant proportional load bearing
that is associated with their more horizontal orientation
(coursing approximately 45 ventral cranialdorsal
caudal).3 These loads are accentuated by the postural
muscle tone that is aimed at supporting the head, whose
center of mass and line of gravity course anterior
through the trunk and produce a perpetual tendency for
the head to fall forward. Thus, joint orientation that is
coupled with increased compressive loading can lend to
ZAJ irritation and pain generation. This tendency can
be further compounded by macrotrauma, as witnessed
after a whiplash injury. Macrotrauma produces greater
involvement of the ZAJ in the cervical spine versus the
other levels, due to the same orientation.4
22 sizer et al.
Unlike the lumbar spine, symptoms associated with
LCS can also stem from irritation to the uncovertebral
joints (UVJ), which are only found in the cervical disc
segments of the spine (C2C3 to C6C7). These unique
joints, which develop more completely in childhood and
early adolescence, can become significant pain genera-
tors. The UVJ demonstrate significant influence on the
control of sidebending and can lead to local cervical
symptoms that are especially aggravated through side-
bending behaviors.5
CBS produces complaints in both the local cervical
region and one or both upper extremities. The upper ex-
tremity pain indicates there is nerve root irritation, which
can stem from either a tension event associated with a
protruded or prolapsed intervertebral disc (1 disc-related
disorder), or a compression event associated with a 2
disc related disorder.6 The compression event, or Nerve
Root Compression Syndrome (NRCS), develops as re-
sult of the segment adapting to degenerative disc changes.
Here, the affliction is not so much due to instability (as
seen in the lumbar spine), but rather to architectural
changes in ZAJ/UVJ. These changes lead to anterior-pos-
terior narrowing of the intervertebral foramen.
Cervico-Cephalic Syndrome produces complaints both
locally in the cervical region and the head (including
headache, dizziness, and tinnitus). These symptoms, if
mechanically activated, can arise from afflictions to the
upper cervical segments, including limitation and insta-
bility. Patients suffering from this category of affliction
can also suffer from Vertebro-Basilar Insufficiency (VBI).
This disorder can be purely mechanical, but is more com-
monly related to sympathetic nervous system dysfunction
and, therefore, is considered to be functional in nature.
On the other hand, Cervico-Medullary Syndrome may
produce local cervical complaints, but is mainly charac-
terized by spinal cord symptoms associated with cord
compression at the cervical spine.
Classification of the Cervical Segments
A clinicians clear understanding of the pathoanat-
omy and mechanics of the cervical spine can serve as
foundation for clarity in differential diagnosis. The first
through seventh cervical segments have been classified
anatomically, biomechanically, and functionally. Ana-
tomically, the cervical spine has been divided into the disc
(C2C3-C6C7) and nondisc (C0C1-C1C2) segments. Bio-
mechanically, C0C1 and C1C2 are collectively labeled as
the upper cervical spine, due to their tendency to synki-
netically sidebend opposite to kinetic rotation. Con-
versely, C2C3C6C7 are labeled as the lower cervical
spine, as they synkinetically sidebend in the same direc-
tion as the kinetic rotation. Additionally, this lower cer-
vical coupling behavior can also be observed from C7T1
to T3T4, allowing those segments to clinically affect the
mechanical behaviors of the segments above.
Functionally, the cervical spine demonstrates many
unique features. First, rotational movement of the head
produces segmental movement caudally to T3T4. This is
also observed with upper extremity elevation, which pro-
duces movement of the thoracic segments from T1T2 to
T5T6. Second, motion at C2C3 is critical to the entire
function of the cervical spine. Motion limits at C2C3 can
restrain movement at C0C1 and C1C2, due to the power-
ful influence of the alar ligaments. Additionally, any mo-
tion limits at C2C3 will negatively influence the sensory
function of the upper cervical spine, as these functions are
directly linked to motion and position of the head.4
Osteology
The vertebral bodies of the cervical disc segments are
short and wide. There is a ridge, particularly posterolat-
eral, where the UVJ can be found. While the pedicles are
very small and run dorsolateral, the laminae are long,
extensive, and can be easily palpated.7 The spinous pro-
cesses from C3-C6 are bifid, typically off-center in their
orientation, and difficult to palpate. Thus, any clinical or
radiological interpretation of segmental malpositioning
is confounded by this asymmetrical tropism. The spinous
process of C2 is particularly large, as it serves as an inser-
tion point for many cervico-occipital muscles. The trans-
verse processes demonstrate 2 tuberculi (anterior and
posterior) that serve as levers for muscles inserting upon
them. These processes form gutters (or sulci) through
which the nerve roots pass. In the lower cervical disc
segments the nerve roots are anchored by connective tis-
sue within these gutters, complicating the use of dural
testing for the detection of a primary disc affliction (Fig-
ure 1).2
One witnesses the intervertebral foramen just proxi-
mal to the sulcus. The spinal nerves course through neu-
ral grooves and then enter the foramen anterior-medial
to the articular processes and lateral to the uncinate pro-
cesses. Because of the unique orientation, the foramena
are best observed on an anterior oblique x-ray. As result
of the bony walls of the canal, patients rarely present
with a pure posterolateral disc protrusion imposing ten-
sion load on the spinal nerve (which would result in
only arm pain). Rather, arm pain related to a disc lesion
will almost always be accompanied by neck pain, by vir-
tue of an irritated posterior longitudinal ligament. When

Figure 1. Cervical Bony Segment, Transverse View. (a) Posterior
transverse tubercle; (b) Anterior transverse tubercle; (c) Vertebral
body; (d) Uncinate process; (e) Transverse process; (f) Transverse
foramen; (g) Spinal foramen; (h) Spinous process; (i) Articular facet.
a patient presents with isolated arm pain, this is not typically
associated with a primary disc affliction, but rather with de-
generative changes in the uncinate and or zygapophyseal ar-
ticular processes. These degenerative changes result in nar-
rowing of the intervertebral foramen, which is especially
observed in a dorsal-ventral direction versus the cranial-
caudal direction that is frequently witnessed in the lumbar
spine.8 The consequences of compression can be clinically
reduced by dorsoventral mobilization to the caudal bony
segment, as this increases the a-p diameter of the canal.2
Ebraheim et al reported that the antero-posterior diame-
ter of the intervertebral foramina was smaller for the C4,
C5, and C6 root levels compared with that associated with
the C3 or C7 levels. Additionally, the length of nerve root
between the lateral border of the dural tube and the medial
border of the vertebral artery gradually increased from C3
(3.3 / 1.1 mm) to C7 (8.1 / 2.1 mm). These investi-
gators reported that a combination of higher uncinate pro-
cess, smaller antero-posterior diameter of intervertebral fo-
ramina, and longer course of nerve roots in close proximity
of the UVJ at the C4 to C6 root levels may explain the pre-
dilection of nerve root compression by uncovertebral osteo-
phytes at these levels. Whereas foraminotomy may decrease
root compression, it may also compromise the stability of
the C-spine, due to uncinate process loss.7
Found in the lateral zone of the cervical disc segment, the
UVJ are comprised of the uncinate process observed on the
caudal vertebra and an indentation on the caudal aspect of
the cranial vertebra (see Figure 2). This joint, which main-
tains the synovial compartment, is intimate with the inter-
vertebral disc as it forms the discs posterior-lateral border.9
The uncinate processes are not present at birth, but instead
Diagnosis of LCS versus CBS 23
Figure 2. Cervical Disc Segments, Frontal View. (a) Uncinate pro-
cess; (b) Sulcus within the transverse process; (c) Vertebral body;
(d) Nucleus, intervertebral disc; (e) Uncovertebral joint; (f) Bony
segments: Cranial convex segment on caudal concave segment.
develop within the first 12 years as result of weightbearing
imposed by the head. The uncinate processes can first be ap-
preciated as they begin to develop at approximately 7 years
of age. By 33-years-old, individuals present with well-devel-
oped uncinate processes and accompanying UVJ.10
The uncinate process, which is curved in shape when
observed from above, demonstrates 3 regions: anterior,
posterior, and foraminal. This architecture allows the
UVJ to enhance the stability of the cervical spine.11,12
The uncinate processes act as a rail to guide transla-
tory behavior of the cranial vertebra on the caudal verte-
bra of a motion segment. As a result, this feature con-
tributes to the regulation of extension and lateral bending
in the cervical disc segments. Penning suggests that the
most prominent (tallest) uncinate process is found at
C2C3 (see Figure 3), by virtue of the increased translatory
movement demonstrated at this segment during flexion/
extension.13 This stabilizing feature develops and changes
with age adjacent to changes in the uncinate processes.1416
The uncinate processes contribute to the reduced inci-
dence of isolated arm pain associated with a primary disc
lesion. The uncinate processes act as a barrier to posterior
lateral disc protrusion or prolapse, reducing the discs ac-
cess to the root. Any disc affliction associated with arm
pain will typically access the root medial to the uncinate
process, irritate the posterior longitudinal ligament, and
create accompanying cervical pain. Furthermore, if the pa-
tient presents with isolated arm pain that is referred in na-
ture, the clinician must suspect a huge prolapse extending
over the uncinate process, a neurinoma, Thoracic Outlet
Syndrome (TOS), foraminal stenosis, or serious pathology.
The ZAJ are formed by the articular processes of two
adjacent cervical segments. These processes are located
24 sizer et al.
Figure 3. Cervical Disc Segments, Sagittal View. (a) Uncinate pro-
cess, C3; (b) Vertebral body, C4; (c) Articular pillar, C4; (d) Spinous
process, C6; (e) Orientation of zygapophyseal joints, pointing to-
wards the orbit; (f) Bony segments: Cranial concabe segment on
caudal convex segment.
just posterior to the transverse processes and are ori-
ented from ventral-cranial to dorsal-caudal at 45 in re-
lation to the vertebral end plate. In general, the articular
surfaces are oriented towards the orbita with the neck in
the zero position (see Figure 3). The presence of the UVJ
and the frontally-inclined position of the ZAJ facets are
among the more important factors causing a strong cou-
pling between kinetic (voluntary, active) and synkinetic
(involuntary, passive) motions.12
The Intervertebral Disc
The intervertebral disc presents a disc to vertebral body
height ratio of 1:4 compared to a 1:3 ratio observed in the
lumbar spine. Whereas the lumbar disc determines the
mechanics of those spinal motion segments, the cervical
disc simply interacts with the influences of both the UVJ
and ZAJ. The cervical disc can develop both mechanical
and chemical phenomena similar to Internal Disc Disrup-
tion (IDD) found in the lumbar spine, thus, rendering it as
a potent pain generator. However, the form and function
of the adult cervical intervertebral disc are considerably
different than that observed in the lumbar spine.17,18
The annulus fibrosus has a series of anular lamella
sheets with collagen fibers oriented at 65 in relation to
the vertical axis in each layer.19,20 The cervical disc nu-
cleus is closer to the center of the disc, and, therefore,
the annulus does not demonstrate the same structural
asymmetry as in the lumbar spine. The key distinctive
feature of the cervical disc is the lateral clefts, or fis-
sures, associated with the UVJ (see Figure 2). The an-
nulus extends beyond the vertebral body and up the
slope of the uncinate process. Along this slope the fis-
sures form over time and ultimately communicate with
the cavity of the UVJ, becoming a component of the UVJ
as they fill with synovial fluid. The fissures develop in
the anular lamellae, and ultimately the adjacent collag-
enous fibers reorient to course parallel with the fis-
sure.15,21,22 Along with the uncinate processes, these clefts
are most prominent from C2C3 to C4C5 and less promi-
nent from C5C6 to C7T1. This prominence is a function of
greater translation in the upper cervical disc segments due
to more caudal location of the instantaneous axis of rota-
tion for flexion/extension. Greater translation merits more
prominent uncinate processes for stability. More promi-
nent uncinate processes induce a greater deformation in
the outer anulus, leading to clefts in the disc. Additionally,
greater uncinate processes reduce pure axial rotation in the
cervical disc segments, requiring coupled synkinetic side-
bending to achieve adequate osteokinematic rotation.
The cervical disc segments ultimately transform into
sellar joints.14,15,25 This transformation is a function of
several factors. First, the functional architecture of the
cervical motion segment contributes to this transforma-
tion. From a sagittal view, the cranial segment is con-
cave on a convex caudal segment (see Figure 3). From a
frontal view, however, the cranial vertebral body is con-
vex on the concave caudal body (especially in the poste-
rior aspect of the intervertebral segment due to uncinate
processes, see Figure 2). Secondly, the fissures in the disc
associated with the UVJ ultimately communicate, reduc-
ing the constraining contribution from the annulus and
rendering the disc to sliding and gliding. The splitting of
the disc is greater from C2C3 through C4C5, due to the
greater translatory motion in those segments. The im-
portant feature to remember is that these changes are
physiological and not pathological in nature.
These physiological adaptations increase linearly with
age. Investigators have demonstrated that 86% and 89%
of discs of asymptomatic men and women over 60 years
of age, respectively, will demonstrate some degree of this
degeneration. However, the findings of degeneration
may not always be clinically relevant.26 This may be ex-
plained by the characteristics of the degenerative event,
where selected segments of the cervical spine demon-
strate degenerative patterns that are different from the
other spinal levels. Whereas the lumbar spine degener-
ates from inside to outside, the upper cervical disc seg-
ments (C2C3 to C4C5) degenerate from outside to in-
side. This pattern contributes to a reduced incidence of
1 disc afflictions in those levels. On the other hand, the
C5C6 to C7T1 segments degenerate from inside to out-
side (likened to lumbar spine). Because of this particular
pattern, patients can experience increased incidence of

1 disc afflictions in these lower cervical levels. Further-
more, the anterior intervertebral disc is the last region of
the disc to degenerate. This is due to the proximity of the
anterior disc to the oblique IAR (Instantaneous Axis of
Rotation) for SB/rotation. Here less rotation occurs, ren-
dering this area to greater stability and reduced degenera-
tion.13 However, if the anterior disc indeed degenerates,
then the patient may present with pain during swallowing
or with palpation to thyroid/crycoid cartilage.
Capsuloligamentous Structures
One can witness synovial-lined capsular structures
surrounding both the ZAJ and UVJ. Mercer and Bogduk
reported the potential for intraarticular inclusions from
the capsule into the cervical synovial joints.17 The most
common of these inclusions are fibro-adipose meniscoid
slips. Less common are thickenings surrounding the en-
tire joint perimeter, or capsular rims, whereas projecting
fat pads are least common. These projections have the
potential for obstructing movement of the cervical mo-
tion segments by becoming lodged between articular
surfaces. The patients who possess these intrusions typi-
cally report variable, unpredictable catching pain that is
local, unilateral, and transient.
The capsule of the ZAJ allows for a great deal of seg-
mental motion, both in rotary and translatory directions
(up to 9 mm at a given level). Most stress is imposed on
the capsular structures during rotation that is performed
in a three-dimensional fashion. Pure sagittal motion can-
not produce enough motion to stress these capsules. On
the other hand, the capsule of the UVJ is best stressed
with three-dimensional sidebending motion. Thus, if the
greatest pain is produced with three-dimensional rota-
tion, the clinician should suspect ZAJ as the primary
pain generator. Conversely, one should suspect UVJ in-
volvement if the greatest pain is produced with side-
bending. Finally, the clinician should suspect the disc as
the primary pain generator if the greatest pain is pro-
duced with flexion and or extension.4
The posterior longitudinal ligament (PLL) is very
prominent and more developed versus the same liga-
ment found in the lumbar spine. Additionally, this liga-
ment provides a greater biomechanical contribution to
motion restraint in cervical spine versus lumbar spine.
The PLL is attached to tectorial membrane and demon-
strates a very tight connection to the disc. This ligament
possesses a rich population of nociceptive endings, ren-
dering it as a potent pain generator in the context of af-
flictions to the posterior and posterior-lateral interverte-
Diagnosis of LCS versus CBS 25
bral disc. Finally, the PLL is a possible site for ossification
and subsequent central stenotic clinical events.27
The anterior longitudinal ligament (ALL) demon-
strates multiple layers and configurations.17 The ALL is
connected to anterior atlanto-occipital and atlanto-axial
membranes in upper cervical spine, contributing to me-
chanical continuity between the head and the cervical
spine. This ligament is also a probable site for ossifica-
tion with increased incidence accompanying diabetes.27
The nuchal ligament is a long connective tissue struc-
ture spanning the entire length of the dorsal cervical
spine. This system demonstrates 2 primary layers: the fu-
nicular layer, coursing cranial-caudal from the tips of the
spinous processes of C5, C6, and C7 up to the occiput;28
and the lamellar layer, coursing in an anterior-posterior
direction from the lamellar layer to the spinous processes
of C2, C3, & C4.29 This ligament possesses insertions
from the trapezius, splenius capitus, serratus posterior
superior, and rhomboid major, suggesting a dynamic
function of the ligament for assisting control of head po-
sition and movement. This ligament may also contribute
to a paradoxical extension of the C0C1 motion segment
during full cervical flexion, explaining why individuals
are capable of producing greater C0C1 flexion during
retraction versus full cervical flexion.30
Neural Structures
When observing the neural structures of the cervical
spine, one must consider both the neural networks linked
to the structures of the cervical spine as well as the nerve
roots exiting the cervical spine. The posterior aspect of
the vertebral motion segment is innervated with 2 differ-
ent layers of the nerve fibers, a superficial and deep net-
work. These layers, especially addressing the posterior
longitudinal ligament and posterior annulus, are respon-
sible for supplying these areas with nociceptive end-
ings.31 The deeper layer is monosegmental, lending to
more focal symptoms. Conversely, the superficial layer is
polysegmentally innervated by the sinuvertebral nerve,
lending to more diffused nonradicular pain patterns
when irritated.32 This may explain why deeper disc af-
flictions present with more localizing symptoms versus
the more diffused nonradicular symptoms associated
with afflictions that reach the outside of the cervical disc
and posterior longitudinal ligament. The medial branch
of the dorsal primary ramus innervates the ZAJ. Once
again, the joints associated with each segmental level are
polysegmentally innervated. This innervation pattern
may contribute to the overlapping nonradicular pain
reference zones associated with afflictions to the ZAJ.33
26 sizer et al.
Ventral rami of C5 to T1 (occasionally as high as C4
and as low as T2) join to create the brachial plexus.
Each root is comprised of several ventral and dorsal
rootlets that emerge from the spinal cord. Each of these
rootlets leaves the spinal cord and traverses to the inter-
vertebral foramen at a different angle. The more cranial
rootlets course in a more dorsal lateral oblique direc-
tion, versus the more horizontal orientation of the more
caudal rootlets of a given segment.34 This relationship is
especially noted at the C5 root level, where any lateral
deviation of the spinal cord may increase the tension
loading in the caudal rootlets at C5. This may explain
why a posterior paramedian primary disc affliction at
C6C7 may result in C5 radiculopathy. As the disc pro-
lapse shoves the spinal cord aside, the lateral movement
loads the C5 root resulting in C5 radiculopathy. Thus,
clinicians cannot trust the presence of a C5 radiculo-
pathy to convince them of a C4C5 disc affliction.
The C7 root maintains several unique characteristics
as well.35 First, it is relatively larger than the other roots
in the cervical spine. Second, the root canal may be
smaller in diameter. Third, the root courses closer to the
facet pillar than other roots. Finally, it courses more lat-
eral in the transverse plane. These features lend the C7
root to frequent compression when the canal is compro-
mised by degeneration associated with secondary disc-
related disorders.
Detecting a primary tension sign during dural tests,
including the slump test and straight leg raise supports
the diagnosis of a primary disc affliction of the lumbar
spine.36 A similar testing paradigm would serve the cli-
nician for diagnosis of cervical primary disc-related dis-
orders. However, the roots C5, C6, and C7 are fixated
on the transverse processes through inter-transverse lig-
amentous anchors. This relationship makes it difficult
for clinicians who wish to use a neural tension test to
identify 1 tension signs in those cervical levels that are
prone to disc afflictions. Thus, alternative testing must
be performed in order to tension load the nerve struc-
tures (to be discussed later).
One may observe anatomical variance in the position
of the dorsal root ganglion within the intervertebral fo-
ramen.37 The ganglion may be found either outside the
bony root window or within it. When positioned within,
the ganglion is more predisposed to bending or kinking
around the pedicle during movements of the upper ex-
tremity or cervical spine. Lu and Ebraheim observed this
phenomenon in 48% of C6 and 27% of C7 root lev-
els.38 This predisposition is enhanced when the disc seg-
ment has degenerated, as the size of the intervertebral
foramen will likely be narrowed. Similar to the lumbar
spine, the dorsal root ganglion is sensitive to pressure
and can result in immediate referred pain. Antitheti-
cally, the upper extremity symptoms that start several
hours or days after the onset of cervical pain or exacer-
bating circumstances are likely due to chemical irrita-
tion of the root itself, as roots are only mechano-sensi-
tive when chemically irritated. Thus, it obligates the
clinician to ask the patient about the time involved in
the onset or provocation of his or her upper extremity
pain, as that timing will indicate whether the root afflic-
tion is mechanical or chemical in nature. This informa-
tion will guide the clinician in selecting a management
strategy, as mechanical root disorders respond more ef-
fectively to mechanical treatments including posterior-
anterior mobilization.23 Conversely, the effects of me-
chanical therapeutic interventions may be less effective
for chemical root irritations and these roots may re-
spond better to pharmacological interventions that are
followed up by root mobilization, which can prevent or
reduce negative consequences associated with chemi-
cally-activated adhesions.
When discussing clinically significant neurological
structures about the cervical spine, one must also con-
sider selected cranial nerves. The spinal accessory nerve
(SAN) is the only cranial nerve without nuclei in the
brain. Rather, the nuclei are located in the brainstem
and spinal cord coursing from C1 to C4 (occasionally,
as far caudal as C6).39, 40 The SAN is the only cranial
nerve that lacks a sensory component and is exclusively
motoric in function. These nuclei innervate the trapezius
muscle, which frequently demonstrates increased tonic-
ity in patients with chronic cervical symptoms. Al-
though this increased muscle activity has been histori-
cally interpreted as a primary muscle lesion associated
with a cervical condition, it may be more related to in-
terneuronal pool firing in the cervical spine. Incoming
nocisensoric impulses from C2 to C6 can be relayed ven-
trally to the motor neurons associated with the SAN via
interneurons. This increase of interneuronal activity
may escalate the motor output of the SAN, elevating the
resting tone in the trapezius. Thus, pain in the midcervi-
cal region can trigger increased muscle tone of the trape-
zius muscles. Furthermore, clinicians must be careful
with the use of trapezius stretching for patients with
neck problems, as this may not address the source of in-
creased trapezial activity, but rather simply aggravate
the underlying cervical condition.4
Branches of trigeminal nerve (opthalmic, maxillary,
and mandibular) are entirely sensory in nature. As with

the SAN, the trigeminal nerve possesses nuclei in the spi-
nal cord from C1 to C4 (possibly C5). In instances of
chronic pain in cervical spine, different adaptive pro-
cesses begin to take place in the spinal cord. Chemical
substances are released in the spinal cord and new inter-
neuronal connections are constructed as the interneu-
rons reorganize. Increased interneuron activity can lead
to cervicotrigeminal relay, where a patient experiences
chronic headache and/or facial pain that is associated
with various different afferent inputs from local cervical
afflictions at mid cervical segments. Whereas cervical
headache is very common (ie, Cervico-Cephalic Syndrome),
it may be due not only to compression of the greater occipi-
tal nerve, but also to irritation of the trigeminal nerve nuclei
in the upper spinal cord.31,41,42 Thus, the clinician must
consider involvement of the cervical disc segments when
evaluating a patients Cervico-Cephalic Syndrome.
Differential Diagnosis of Afflictions
in Cervical Disc Segments
Cervical Postural Syndrome. Cervical Postural Syndrome
(CPS), although not belonging to any other category of
syndromes, is closely related to the onset of primary disc-
related disorders. Onset of CPS is linked to imbalance of
muscle activity within the cervico-thoracic spine. The
muscles of the cervical spine encounter overload when
the head is positioned too far forward, increasing the
flexion movement at the lower cervical segments and
compensatory muscular response in the dorsal muscula-
ture. This tired neck is frequently experienced by indi-
viduals involved in activities requiring static forward bent
posturing such as drafting technicians, computer operators,
and students. This condition is seen more frequently in
women vs. men (3:1) and is perpetuated by bifocal use and
prolonged driving. Clinically, individuals (from 6 to 40
years of age) will complain of a tired feeling in their necks,
stiffness, and potential symptoms in the TMJ. They may
present with tenderness, but frequently present with a nega-
tive functional examination, where movement and force do
not provoke the symptoms. These patients are best managed
through postural reeducation, isometrics for strengthening,
and local infiltration to muscle trigger-point regions.2
Local Cervical Syndrome. One can describe LCS as a dis-
order that presents with complaints that are local and re-
ferred in a nonradicular distribution. Pain related to LCS is
typically aching in nature and extends from C2C3 down
to midthoracic levels. Dwyer et al demonstrated that
pain associated with each segmental level overlaps, po-
Diagnosis of LCS versus CBS 27
tentially extending far below the level of origin (see Fig-
ure 4).33 Due to these nonradicular referral patterns, a
clinician must consider a cervical origin for patients
pain that extends into the interscapular region.
For LCS that is 1 disc-related, the patient suffers due
to pain generation from the disc itself, as the disc is a
structure with the capacity for generating both prioprio-
ceptive and nociceptive afferent information. The most
frequent disc levels to present as LCS are C5C6 and
C6C7, due to the previously mentioned inadequate un-
cinate processes, as well as the characteristic internal de-
generative changes. Patients may experience pain with
swallowing (due to instantaneous cervical flexion dur-
ing a swallow) and motions that impose either a tension
or compression load on the disc. Pain associated with
this local cervical disorder, however, is not limited to the
cervical spine and cervico-thoracic junction. Shellhas et
al were able to provoke symptoms in seemingly dubious
locations around the head, neck, and shoulder girdle re-
gions (see Table 1).43 Thus, the cervical intervertebral
disc can be responsible for pain in otherwise unsus-
pected areas, such as the cranium, jaw region, throat,
anterior chest, and scapula.
LCS associated with a 1 disc affliction can be classi-
fied into 1 of 2 different subcategories: (1) acute torti-
collis or (2) disc protrusion. Acute torticollis is seen
most frequently in children and young adults as result of
sustained poor posturing (eg, during sleeping) in a side-
bent and rotated position. While individuals normally
change position frequently at night, sleeping pills, alco-
hol, or extreme fatigue will lead a person to maintain a
single position throughout the entire sleep cycle. During
this time, the discs nuclear material can migrate into the
lateral fissure of the UVJ on the contralateral side to the
sidebent position. After waking, patients develop ex-
treme stiffness and local pain in the cervical spine. They
present with a head laterally shifted away from the pain.
Motion is limited in a noncapsular pattern of extension,
ipsilateral sidebending, and ipsilateral rotation. This
Figure 4. Nonradicular pain reference zones for the cervical zyg-
apophyseal joints. Adapted from Dwyer A, Aprill C, Bogduk N.
Cervical zygapophyseal joint pain patterns I: A study in normal
volunteers. Spine. 1990; 15:453-461.
28 sizer et al.

Table 1. Discogenic pain reference patterns of the plished by first flexing the neck forward, followed by re-
cervical disc segments. traction of both scapulae (Disc Test 1, see Appendix A).
Involved Disc Level Here, the retraction event can increase the tension load-
ing of the T1 root level, thus, loading the cervical spinal
Region of Pain C3C4 C4C5 C5C6 C6C7
dura and more cranial roots by virtue of the short dis-
Mastoid * * tances any rootlet courses from the spinal cord to the
Temple *
Jaw * root anchors. This increased tension will provoke the
TMJ * patients local cervical symptoms, whereas the same
Parietal Cranium * *
Occipital Cranium * * *
symptoms would not be aggravated in the case of ZAJ
Craniovertebral Junction * * * or UVJ involvement. This back door technique may
Neck * * * *
be sensitive and specific for the detection of primary disc
Throat * * *
Upper Back * * * afflictions that would otherwise be confusing and
Trapezius * * * * vague.4
Top of Shoulder * * * *
Upper Extremity * * * * LCS can also be related to 2 disc-related disorders.
Anterior Chest * * * Local cervical symptoms can stem from long-standing
Scapula *
changes in the disc and articular structures of the cervi-
Adapted from Shellhas KP, Smith MD, Gundry CR, Pollei SR. Cervical discogenic pain. cal spine that were triggered by previous intradiscal deg-
Prospective correlation of magnetic resonance imaging and discography in asymp-
tomatic subjects and pain sufferers/. Spine. 1996;21:300312. radation. This family of disorders can include: (1) annu-
lar tears with IDD; (2) UVJ afflictions; and/or (3) ZAJ
afflictions. Patients with LCS that is associated with in-
commonly experienced crick in the neck can be inter- ternal disc disruption present with vague, and often con-
preted as a disc affliction as evidenced by difficulty in fusing, symptoms. The condition is regularly associated
sidebending towards the side of pain. This affliction is with chronic irritation to the disc and is related to a
regularly self-limiting, but recovery can be encouraged chemical cascade that was initiated earlier in the disc
through soft tissue mobilization, axial separation in the with apparently innocuous trauma. With trauma to the
deviated position with correction in rotation and side- nuclear envelope of the disc, chemical factors enter the
bending, and short-term use of a firm cervical collar.2 disc, triggering the production of Metallo-Matrix Pro-
Patients with a LCS that is associated with protrusion tease Inhibitors (MMPIs) that initiate deterioration of
present with a characteristic profile. These patients are the internal environment of the disc anulus.45 This pro-
more commonly between the ages of 30 and 45 years cess is accentuated by collagenase release and is accom-
with episodic histories of acute torticollis.2 Pain is again panied by autoimmune activities, including the release
distributed in previously mentioned nonradicular areas of bradykinin and serotonin, the aggregation of T-lym-
and is exacerbated with forces that stress the discs an- phocytes, and the production of phospholipase A2
nulus with either compression or tension loads. Exami- (PLA2), which facilitates production of prostaglandins
nation of the MRI may or may not reveal the protrusive and leukotrienes.45,46 These responses sensitize silent
event. Patients typically demonstrate the most pain dur- nociceptors in the outer sanctum of the disc, leading to a
ing movements in the sagittal plane (flexion and or ex- painful response even under loading and movement con-
tension), due to increased mechanical loading5 and in- ditions that were previously considered normal.
tradiscal pressure44 that can be especially demonstrated The diagnosis of cervical IDD is difficult at best. Pa-
in the lower cervical disc segments. Additionally, the tients present with local and nonradicular symptoms
pain is also provoked during sidebending and or rota- that are most easily provoked by movements in the sag-
tion towards the painful side. Because the nonradicular ittal plane (flexion and or extension) that produce ten-
pain can arise from the posterior annulus, posterior lon- sion and or compression in the discal structures. Patients
gitudinal ligament, and dura of the root, tension loading report stiffness in the early morning and increased
in the root may provoke the symptoms. Motor, sensory, symptoms by the end of the day. Pain is located in the
and reflexive tests are typically negative. While a stan- midline and either unilateral or bilateral paramedian re-
dard neural tension test may not provoke these symp- gions of the cervical spine. The pain is aching in nature
toms (due to the anchoring of the C5, C6, and C7 roots and is typically long-standing. Patients may or may not
in the sulcus of the transverse processes), a clinician can present with motion limits and the previously men-
nevertheless increase root tension loading. This accom- tioned dural tension test will be negative, along with
 Diagnosis of LCS versus CBS 29

negative motor and or sensory findings. Conclusively,

IDD may appear to be very similar to LCS associated
with the ZAJ or UVJ. Thus, the IDD diagnosis should be
made in exclusion of joint involvement from the local ex-
amination findings that will be discussed next.
While the cervical disc segments can produce observ-
able radiographic changes associated with disc protru-
sion, internal disc disruption can be absent of any find-
ings on standard MRI or CT, making the diagnosis
more challenging for the clinician. However, patients
suffering from IDD frequently present with a loss of cer-
vical lordosis, as witnessed on sagittal imaging. Reduced
lordosis is associated with accelerated discosis, whereby
the disc height diminishes, the cranial vertebral body of
a motion segment descends and contacts the posterior
curve of the uncinate process, and further disc height
loss forces the cranial bony segment to tip forward
(see Figure 5). This angulation is typically accompanied
by a posterior shift of the discs nucleus, which progres-
sively disintegrates with further changes.23 These changes
can be useful to the diagnostician, as a reduced cervical Figure 5. Anterior kinking of cervical disc segments associated
lordosis on the imaging can suggest IDD and discosis. with accelerated cervical disc degradation.
These patients will present with a non-capsular pattern
demonstrating a disproportional loss of extension due Similar to the lumbar spine, pain can emerge from the
to pain, while rotation and sidebending are often found ZAJ, as these joints experience significant proportional
to be within normal limits. Symptoms and the loss of load bearing that is associated with their more horizon-
lordosis can be reduced through posterior-anterior mo- tal orientation (coursing approximately 45 ventral cra-
bilization and specific home exercises.23 nialdorsal caudal).3 These loads are accentuated by
Unlike the lumbar spine, symptoms associated with the postural muscle tone that is aimed at supporting the
LCS can also stem from irritation to the UVJ, which are head, whose center of mass and line of gravity course
only found in the cervical disc segments of the spine anterior through the trunk and produce a perpetual ten-
(C2C3 to C6C7). These unique joints, which develop dency for the head to fall forward. Thus, joint orienta-
more completely in childhood and early adolescence, tion that is coupled with increased compressive loading
can become significant pain generators. The UVJ dem- can lend to ZAJ irritation and pain generation. This ten-
onstrate significant influence on the control of sidebend- dency can be further compounded by macrotrauma, as
ing and can lead to local cervical symptoms that are es- witnessed after a whiplash injury. Macrotrauma pro-
pecially aggravated through sidebending behaviors.5,11 duces greater involvement of the ZAJ in the cervical spine
Conversely, sidebending is typically not the greatest versus the other levels due to the same orientation issues.
pain-producing motion in a cervical IDD, due to an ac- LCS associated with ZAJ irritation must be differen-
tual decrease in intradiscal pressure at end range of the tially diagnosed from internal disc disruption and/or
motion.44 Neither is this motion most provocative with UVJ afflictions. Unlike a cervical disc affliction, the
ZAJ afflictions, due to the apparent laxity in the cap- greatest pain provocation associated with ZAJ synovial
sule. Onan et al observed 28 of isolated segmental side- irritation is not witnessed during flexion and or exten-
bending allowed by the ZAJ capsule, which again far ex- sion. This is related to the apparent laxity of the joint
ceeds the physiological motion demonstrated by any capsule during those movements. Onan et al observed
cervical segments.47 However, sidebending can induce that isolated facet joints allowed up to 19 of segmental
increased pressure and irritation to the posterior and fo- flexion and 14 of segmental extension, which far ex-
raminal portions of the uncinate process on the side ipsi- ceeds the movements that physiologically occur in the
lateral to the direction of sidebending, as well as increased sagittal plane at any give cervical motion segment.47
tension on the UVJ capsule on the contralateral side.11 This suggests that flexion and or extension are not suffi-
30 sizer et al.

cient to tension load the capsule of the joints. Rather,

rotation appears to maximally tension load the ZAJ
capsule, suggesting the primary role of the ZAJ in con-
trolling rotation. Furthermore, while extension does in-
crease the loading on the ZAJ articular surfaces, the
same symptoms can be provoked with contralateral ro-
tation and ipsilateral sidebending (by virtue of the load-
ing in the contralateral ZAJ with these motions). This
behavior allows for differential diagnosis from a cervical
IDD, which will also provoke greatest pain during ex-
tension but not during the previously mentioned three-
dimensional motion.5
Therefore, a clinician must differentiate between 5
different local conditions associated with 2 disc-related
disorders: (1) internal disc disruption and discosis; (2)
synovitis of the UVJ; (3) arthropathy of the UVJ; (4)
synovitis of the ZAJ; and (5) arthropathy of the ZAJ. Al-
though this differential diagnosis is not simple at face
value, it is necessary to guide the clinician to a more ex-
pedient management strategy. The differential diagnosis
can be determined through a brief, but specific, three-
dimensional provocative examination (see Appendix B).
The examination is divided into 5 different test catego-
ries: (1) active Sagittal motions (Flexion/Extension); (2)
active & passive rotation; (3) active & passive sidebend-
ing; (4) active & passive three-dimensional rotation; and
(5) active & passive three-dimensional sidebending. Pas-
sive tests are only conducted if the patients hesitance
does not allow the clinician to provoke the symptoms
through active testing, and many times the active tests
are sufficient for effective differential provocation.
The first motions performed in the examination are
flexion and extension. If the patient suffers from disc in-
volvement, these sagittal motions will induce the great-
est provocation, versus planar and or three-dimensional
movements in the directions of sidebending or rotation
(Figure 6). One can note that this provocation can be
greatest with flexion, extension or retraction. These
provocation patterns are related to tension and or com-
pression events in the disc, addressing specific structures
in an age-specific fashion. The second set of motions in
the exam (frontal plane motions) involves sidebending.
While the clinician can begin to suspect uncovertebral
involvement when planar sidebending is most provocative,
this diagnosis can be strengthened with three-dimensional
movements. The three-dimensional sidebending move-
ments produce either a coupled or combined motion in the
cervical disc segments. Coupled motion is one where a
synkinetic motion predictably occurs in response to a ki-
netic motion, allowing maximal motion in the kinetic
Figure 6. Interpretation of Local Cervical Syndrome: Greatest
Pain Provocation in Sagittal Plane Motions.
direction and the capsular structures to reach their max-
imum tension load. The coupled motions of the cervical
spine are sidebending and ipsilateral rotation. Com-
bined motions, on the other hand, limit the kinetic mo-
tion by adding a second motion that contradicts the nor-
mal synkinetic behavior of the segment. This reflects the
articular surfaces getting in the way of the motion and
locking the segment. For the cervical spine, combined
motions are sidebending and contralateral rotation.2
The first three-dimensional movement is performed
by initiating sidebending, accompanied by rotation in 2
different directions. After the sidebending is initiated,
the patient then rotates to the ipsilateral side, producing
a coupled motion. Here, the capsule and synovium of
the UVJ are maximally stressed on both the ipsilateral
and contralateral sides to the direction of sidebending. If
these tests maximize provocation, then the clinician should
suspect synovitis of the UVJ (Figure 7). Next, the sidebend-
ing is accompanied by contralateral rotation, where the ar-
ticular surfaces of the UVJ are compressed on the side ipsi-
lateral to the direction of sidebending. If this test is most
provocative, then one may strongly suspect an UVJ arthr-
opathy as the principal pain generator (Figure 8). Con-
versely, if the same test provokes most pain on the con-
tralateral side of sidebending, then the clinician can be more
suspicious of an IDD, as the UVJ on that side is unloaded.
If the patient suffers from ZAJ involvement, the pain
produced during planar and or three-dimensional rota-

Figure 7. Interpretation of Local Cervical Syndrome: Greatest
Pain Provocation in Sidebending and Coupled Rotation Move-
ments.
tion will be greatest, as the ZAJ are most responsible for
controlling rotation of the cervical disc segments. Thus,
the third set of motions in the exam (transverse plane
motions) involves rotation. First, the patient rotates and
then ipsilaterally sidebends to produce a coupled motion.
Flexion and extension are each superimposed onto this
coupled motion. These motions are added because rota-
tion produces osteokinematic extension from C0C1 to
C3C4 and extension from C4C5 to C7T1. Additionally,
rotation produces arthrokinematic extension on the ipsi-
lateral ZAJ and flexion on the contralateral joints.
Diagnostically, if a combination of rotation, ipsilat-
eral sidebending, and extension is the most provocative
movement in the upper cervical disc segments on the
Figure 8. Interpretation of Local Cervical Syndrome: Greatest
Pain Provocation in Sidebending and Combined Rotation Move-
ments.
Diagnosis of LCS versus CBS 31
same side as rotation, then the clinician should suspect
ZAJ synovitis at C2C3 or C3C4. This is because this
movement maximally extends the upper ZAJ and maxi-
mally stresses the capsule, along with the synovial lin-
ing. However, if pain is produced those same segments
on the opposite side to rotation, then the clinician
should suspect IDD. Conversely, if rotation, ipsilateral
sidebending, and flexion produce the most pain in the
lower cervical disc segments on the opposite side to ro-
tation, then the clinician should again suspect ZAJ syno-
vitis in that region. This is because the contralateral
lower ZAJ is maximally flexed and the capsule is maxi-
mally stressed on that side. Furthermore, if pain is pro-
duced in those same segments on the same side as rotation,
then the clinician should suspect IDD at those levels (Fig-
ure 9). Finally, the patient performs a combined motion of
rotation and contralaterally sidebending. If the greatest pain
is produced during this movement on the same side as the
sidebending, then the clinician should suspect ZAJ arthrop-
athy, due to the compression of the joint surfaces during
combined motion (Figure 10).
After the suspected structure of involvement has been
identified (Disc, UVJ or ZAJ), the clinician can use a
mobility test to propose the segmental level of involve-
ment. This test is performed by positioning the patient
in cervical sidebending to the corresponding segmental
level (determined by palpating the closure of the ZAJ)
and providing overpressure in a direction contralateral
to the sidebending. The segment that produces the great-
est local pain with brief overpressure would be the seg-
ment that the clinician could suspect as the pain genera-
tor.2 Although this test outcome may be clouded by
Figure 9. Interpretation of Local Cervical Syndrome: Greatest
Pain Provocation in Rotation and Coupled Sidebending Move-
ments.
32 sizer et al.
Figure 10. Interpretation of Local Cervical Syndrome: Greatest
Pain Provocation in Rotation and Combined Sidebending Move-
ments.
referred tenderness, it provides a starting point for the
clinician in administering appropriate treatments.
Cervical Brachial Syndrome
One can describe Cervical Brachial Syndrome (CBS)
as a disorder that presents with complaints in both the
local neck and upper extremity, due to either 1 or 2
disc-related conditions. The neck pain associated with
CBS is typically aching in nature and extends from
C2C3 down to midthoracic levels, as observed with
LCS. These symptoms in the neck are related to the
same processes previously described and can be typically
provoked with similar testing. The arm pain associated
with CBS is related to either irritation of the dorsal root
ganglion or the root itself, and is related, for the most
part, to the size of the spinal canal, intervertebral fora-
men, and or sulcus within the transverse process.2 The
arm pain associated with dorsal root ganglion irritation
is sharp and immediate upon mechanical stimulus, as a
dorsal root ganglion is mechano-sensitive.48 The pain
associated with root compression demonstrates a slow
onset and is aching in nature. This root irritation is the
consequence of vascular compromise and an inflamma-
tory cascade that sensitizes the nerve root. Once chemi-
cally sensitized, the cervical root then becomes mech-
ano-sensitive, as described for the lumbar spine.45
Upper extremity pain that is associated with a cervi-
cal disorder is typically accompanied by cervical pain.
When the patient presents with isolated upper extremity
pain, the clinician should suspect other pathologies,
such as disorders of the shoulder, TOS, neurinoma, or
pancoast tumor.2,6 Individuals with TOS commonly
present with distal upper extremity pain in a nonradicu-
lar distribution associated with the lower trunk and me-
dial cord of the brachial plexus (C8-T1). Their symp-
toms are provoked with upper extremity elevation and
use versus a release phenomenon causing sleep distur-
bances in the early hours of the morning. Neurinoma
produces pain and sensory changes that begin distal and
radiate proximally. Symptoms associated with a pan-
coast tumor can be elusive, but many times can be accom-
panied by other organic signs such as malaise, lethargia,
dry cough, and weight loss. Additionally, the upper ex-
tremity symptoms are not easily provoked through physi-
cal examination and may be more profound at night.
A clinician should differentiate a cervical patients up-
per extremity pain as related to 1 versus 2 disc-related
changes. Upper extremity symptoms associated with a 1
disc-related disorder accompany the local cervical symp-
toms previously discussed, due in part to the irritation of
a well-developed posterior longitudinal ligament. Pri-
mary disc-related CBS is typically observed in patients
younger than 45 years of age, who commonly report nu-
merous previous episodes of LCS. The root tension
event is associated with disc protrusion or prolapse, es-
pecially at C5C6 or C6C7. This soft disc lesion is typi-
cally preceded by direct or indirect trauma that has oc-
curred recently or in the past. These lesions produce
radicular pain that can be provoked with coughing,
sneezing, or straining. The pain is worse in the morning,
due to the increased water content of the disc, and can
be accompanied by parasthesias associated with vaso-
neurvorum irritation producing a relative ischemic
event. More extensive disc lesions may produce motor
deficits and numbness, depending on the size of the spi-
nal canal. As previously mentioned, radicular symptoms
are frequently observed at the C5 root level, due to the
configuration of the rootlets. Symptoms are also com-
monly observed in the C6 and C7 distribution. Serious
pathology must be ruled out if patients in this age group
present with radicular symptoms at more cranial root
levels, due to the low frequency of 1 disc lesions at
higher levels.6,49
Physical examination of these patients produces the
limitation patterns that are similar to the 1 disc-related
LCS. The patient may experience increased neck and up-
per extremity pain when the shoulder girdles are re-
tracted with the neck in a forward bent position (as pre-
viously discussed). In addition, patients may report
increased arm symptoms associated with cervical side-
bending in a direction contralateral to the side of upper
extremity pain, due to increased neural tension around

the disc prolapse (Disc Test 2, see Appendix A). When
this pain is reduced by passively abducting the patients
painful shoulder while the neck is sidebent in this fashion,
then the 1 disc-related diagnosis is confirmed. This con-
dition is best treated with physical agents, gentle soft tis-
sue techniques, cervical traction, home exercise, and pos-
sible anaesthetic procedures when the symptoms persist.
Upper extremity symptoms associated with a 2 disc-
related disorder are associated with a NRCS. Although
the symptoms can be isolated to the upper extremity,
they can also be accompanied by local cervical symp-
toms previously discussed, due in part to the irritation of
the UVJ and or ZAJ. Nerve NRCS is more frequently as-
sociated with bony changes versus forminal narrowing
from instability, as witnessed in the lumbar spine. The
degenerative changes associated with UVJ and ZAJ com-
monly leads to exostosis, which can account for the front-
back narrowing of the intervertebral foramen and sulcus.
In addition, the intervertebral foramen can narrow in an
up-down direction, due to settling of the cranial vertebral
body in response to disc degeneration. The area of the in-
tervertebral foramen can decrease as much as 40% to
45% with a mere 3 mm settling of the cranial body.38
This NRCS is more frequently seen with individuals
older than 45 years of age, who typically have a long-
standing history of local cervical problems. The pain
demonstrates a gradual onset, is provoked towards the
end of the day and can be accompanied by parasthesias,
sensory loss, and possibly motor disturbances. These pa-
tients present with capsular pattern motion limitations
that include reduced extension, bilateral sidebending and
rotation. These limitations are associated with long-stand-
ing degenerative changes and may or may not be painful or
clinically relevant. Using a modified Spurling test can most
easily provoke the upper extremity symptoms. Here, the
clinician places the patients head and neck in extension
plus ipsilateral rotation and sidebending. While stabilizing
the contralateral shoulder, the clinician then provides sus-
tained axial compression to the head and neck from above.
If the patient suffers from a NRCS, then the symptoms are
provoked in the upper extremity. Conservative manage-
ment of NRCS can include neural flossing, ventral dorsal
mobilization to the caudal bony segment, and anaesthetic
procedures. Symptoms that persist can be managed by sur-
gical intervention including dorsal foramenotomy, anterior
discectomy and fusion, or anterior foramenotomy.29
CONCLUSIONS
Afflictions of the cervical spine can be associated
with either a 1 or 2 disc-related disorder. These condi-
Diagnosis of LCS versus CBS 33
tions can present as a LCS, which produces cervical pain
that is local and referred in a nonradicular distribution.
A 1 disc-related LCS can be classified as either an acute
torticollis or a disc protrusion, while a 2 disc-related
LCS is associated with either chronic disc irritation or
arthropathy of the UVJ and or ZAJ. Patients may also
develop upper extremity symptoms associated with a 1
or 2 disc-related disorder. Tension on the dorsal root
ganglion and nerve root can be caused by a disc protru-
sion or prolapse, leading to a 1 disc-related CBS. NRCS
can be caused by 2 disc-related changes that produce
front-back and or up-down compromise to the interver-
tebral foramen. A clinicians careful examination and
differential diagnosis of these disorders can serve as a
pathway to expedient and effective management.
REFERENCES
1. Bland JH. Epidemiology and demographics: phylogen-
esis and clinical implications. In: JH Bland, ed. Disorders of the
Cervical Spine. Diagnosis and Medical Management. 2nd ed.
Philadelphia, Pa: WB Saunders Co; 1994:310.
2. Winkel D, Aufdemkampe G, Matthijs O, Meijer OG,
Phelps V. Diagnosis and Treatment of the Spine: Nonoperative
Orthopaedic Medicine and Manual Therapy. Gaithersburg:
Aspen Publishers, Inc.; 1996.
3. White AA III, Panjabi MM. Clinical Biomechanics of
the Spine. 2nd ed. Philadelphia, Pa: JB Lippincott; 1990.
4. Matthijs O. Clinical Patho Anatomy. Proceedings from
conference on the Nonoperative Orthopaedic Medicine and
Manual Therapy of the Lower Cervical Spine. Minneapolis,
Minn: International Academy of Orthopaedic Medicine; 1999.
5. Goel VK, Clausen JD. Prediction of load sharing
among spinal components of a C5-C6 motion segment using
the finite-element approach. Spine 1998;23:68491.
6. Manifold SG, McCann PD. Cervical radiculitis and
shoulder disorders. Clin Orth Rel Res 1999;368:10513.
7. Ebraheim NA, Lu J, Biyani A, Brown JA, Yeasting RA.
Anatomic considerations for uncovertebral involvement in cer-
vical spondylosis. Clin Orthop Rel Res 1997;334:20006.
8. Ebraheim NA, An HS, Xu RM, Ahmad M, Yeasting RA.
The Quantitative Anatomy of the Cervical Nerve Root Groove
and the Intervertebral Foramen. Spine 1996;21:161923.
9. Stahl C, Huth F. [Morphological evidence of synovial
spaces in the uncovertebral region of cervical discs]. Z Orthop
1980;118:72128.
10. Tillman B, Tondury G, Ziles K. [Human Anatomy: Lo-
comotor System]. Stuttgart: Thieme; 1987:219.
11. Kotani Y, McNutty PS, Abumi K, Cunningham BW,
Kaneda K, McAfee PC. The role of the anteromedial foramino-
tomy and the uncovertebral joint in the stability of the cervical
spine. Spine 1998;23:155965.
12. Clausen JD, Goel VK, Traynelis VC, Scifert J. Uncinate
34 sizer et al.
processes and luschka joints influence the biomechanics of the
cervical spine-Quantification using a finite-element model of
the C5-C6 segment. J Orthop Res 1997;15:34247.
13. Penning L. Differences in anatomy, motion develop-
ment and aging of the upper and lower cervical disc segments.
Clin Biomech 1988; 3:3747.
14. Ecklin U. [Age related changes of the cervical spine].
Berlin: Springer; 1980.
15. Hall MG. Luschkas Joint. Springfield: Thomas; 1960.
16. Tondury G. Entwicklungsgeschichte und fehlbildun-
gen der halswirbelsaule. Stuttgart: Hippokrates Verlag; 1958.
17. Mercer S, Bogduk N. Intra-articular inclusions of the
cervical synovial joints. Br J Rheumatol 1993;32:705710.
18. Mercer S. Invited commentary. JOSPT 2000;30:1012.
19. Ghosh P. The biology of the intervertebral disc. Vol. 1.
Boca Raton, Fla:CRC Press Inc; 1988.
20. Pooni JS, Hukins DW, Harris PF, Hilton RC, Davies
KE. Comparison of the structure of the human intervertebral
disc in the cervical, thoracic and lumbar region of the spine.
Surg Radiol Anat 1986;8:175182.
21. Frykholm R. Lower cercial vertebrae and interverte-
bral disc, Surgical anatomy and pathology. Acta Orthop Scand
1951;101:34559.
22. Hirsch C, Schajowicz F, Galante J. Structural changes
in the cervical spine. Acta Orth Scanf. 1967;109(suppl):377.
23. Jenkner FL. Das cervikalsyndrom:Manuelle und elek-
trische therapie. Vienna: Springer Verlag; 1982.
24. Penning L, Wilmink JT. Rotation of the cervical spine:
A CT study in normal subjects. Spine 1987;12:73238.
25. Tondury G. Angewandte und Topogrphische Anat-
omie. Stuttgart: Thieme Verlag; 1981.
26. Matsumoto M, Fujimura Y, Suzuki N, Nishi Y, Naka-
mura M, Yabe Y, Shiga H. MRI os cervical intervertebral discs
in asymptomatic subjects. J Bone Joint Surg 1998; 80B:1924.
27. Shingyouchi Y, Nagahama A, Niida M. Ligamentous
ossification of the cervical-spine in the late middle-aged japa-
nese menIts relation to body-mass index and glucose-metab-
olism. Spine 1996;21:247478.
28. Van der El. [Wervelkolom. Manuele Diagnostiek].
Rotterdam: Manthel; 1992.
29. Johnson JP, Filler AG, McBride DQ, Batzdorf U. Ante-
rior cervical foramenotomy for unilateral radicular disease.
Spine 2000;25:90509.
30. Ordway NR, Seymour RJ, Donelson RG, Hojnowski
LS, Edwards WT. Cervical flexion, extension, protrusion, and
retraction. A radiographic segmental analysis. Spine 1999;24:
24047.
31. Imai S, Konttinen YT, Tokunaga Y, et al. An ultra-
structural study of calcitionin gene-related peptide-immunore-
active nerve fibers innervating the rat posterior longitudinal
ligament. Spine 1997;22:194147.
32. Bogduk N. The anatomical basis for cervicogenic head-
ache. J Manipulative Physiol Ther 1992;15:6770
33. Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal
joint pain patterns I: a study in normal volunteers. Spine 1990;
15:45361.
34. Shinomiya K, Okawa A, Nakao K, et al. Morphology
of C5 ventral nerve rootlets as part of dissociated motor loss of
deltoid muscle. Spine 1994;19:250104
35. Ebraheim NA, Xu R, Stanescu S, Yeasting RA. Ana-
tomical Relationship of the cervical nerves to the lateral
masses. Am J Orthop 1999;28:3942.
36. Stancovic R, Johnell O, Maly P, Willner S. Use of lumbar
extension, slump test, physical and neurological examination in
the evaluation of patients with suspected herniated nucleus pul-
posus. A prospective clinical study. Man Ther 1999;4:2532.
37. Yabuki S, Kikuchi S. Positions of dorsal root ganglia in
the cervical spine. An anatomic and clinical study. Spine 1996;
21:151317.
38. Lu J, Ebraheim NA, Huntoon M, Haman SP. Cervical
intervertebral disc space narrowing and size of intervertebral
foramina. Clin Orthp Rel Res 2000;370:25964.
39. Kandel ER, Schwartz JH, Jessell TM. Principles of Neu-
roscience. 3rd ed. Norwalk, Conn: Appleton & Lange; 2000.
40. Oostendorp R. Functional vertebrobasilar insuffi-
ciency [doctoral thesis]. University of Nijmegen, The Nether-
lands: 1988.
41. Gawel MJ, Rothbart PJ. Occipital nerve block in the
management of headache and cervical pain. Cephalalgia. 1992;
12:913.
42. Jansen J, Markakis E, Rama B, Hildebrandt J. Hemi-
cranial attacks or permanent hemicraniaa sequel of upper
cervical root compression. Cephalalgia. 1989;9:12330.
43. Shellhas KP, Smith MD, Gundry CR, Pollei SR. Cervi-
cal discogenic pain. Prospective correlation of magnetic reso-
nance imaging and discography in asymptomatic subjects and
pain sufferers. Spine 1996;21:30012.
44. Pospiech J, Stolke D, Wilke HJ, Claes LE. Intradiscal pres-
sure recordings in the cervical spin. Neurosurg 1999;44:37985.
45. Siddall PJ, Cousins MJ. Spine update: Spinal pain
mechanisms. Spine 1997;22:98104.
46. Saal JS. The role of inflammation in lumbar pain.
Spine. 1995;20:18211827.
47. Onan OA, Heggeness MH, Hipp JA. A motion analysis
of the cervical facet joint. Spine 1998;3:43039.
48. Bandalamente MA, Dee R, Ghillani R, Chien PF, Daniels
K. Mechanical stimulation of dorsal root ganglion induces in-
creased production of substance P: A mechanism for pain follow-
ing nerve root compromise? Spine 1987;12:55255.
49. Kelsey JL, Githens PB, Walter SD, et al. An epidemio-
logical study of acute prolapsed cervical intervertebral disc.
J Bone Joint Surg 1984;66A:90714.
 Diagnosis of LCS versus CBS 35

Appendix A. Functional Examination of the Cervical Spine

Inspection:
Resisted Cervical Extension
Resisted Cervical Rotation Right Left
Resisted Cervical Sidebending Right Left
Resisted Cervical Flexion
Motor Screening Muscle Grade Root level
Resisted Sh. Girdle Elevation C2-C4
Resisted Sh. ABduction C5
Resisted Sh. ADduction C7
Resisted Sh. Internal Rotation C5, C6
Resisted Sh. IExternal Rotation C5, C6
Resisted Elbow Flexion C5, C6
Resisted Elbow Extention C7
Resisted Wrist Palmar Flexion C7
Resisted Wrist Dorsal Extention C6
Resisted Thumb Extention C8
Resisted 5th digit Abduction T1
Sensory Screening C6 C7 C8
Reflexes BrachioRadialis C5 Biceps C5, C6 Triceps C7
Special Tests Test Outcomes
Spurling Test (Foraminal Compression)
Disc Test 1 (Flexion Sh. Retraction)
Disc Test 2 (Contra SB Sh. ABduction)
Comments:

Appendix B. Local Examination of the Lower

Cervical Spine

Active Sagittal Motions Provocation Location of Sxs

Flexion
Extention
Retraction
Frontal Motions Active
Passive Provocation Location of Sxs
Sidebend (R)
with (R) Rot
with (L) Rot
Sidebend (L)
with (L) Rot
with (R) Rot
Transverse Motions Active
Passive Provocation Location of Sxs
Rotation (R)
with (R) SB, Flex
with (R) SB, Ext
with (L) SB
Rotation (L)
with (L) SB, Flex
with (L) SB, Ext
with (R) SB
Comments: